Depression

Please introduce yourself briefly

I’m Dan Tomasulo, MAPP 7. Since graduation in 2012 I’ve worked as an assistant instructor for Marty Seligman and James Pawelski. I’m also core faculty for the “Spirituality Mind Body Institute” at Teachers College, Columbia University in NYC where I’ve designed and teach the Optimal Well-Being concentration. I also direct the Open Center’s New York Certificate in Applied Positive Psychology (NYCAPP).

What did you do before joining the MAPP program at Penn?

Hmmm. Depends on how far back we are willing to look. 🙂 I’m a licensed psychologist and psychodrama trainer and work in private practice and consulting. I also have an MFA in writing and a few books under my belt. I have a daily blog called Ask the therapist at Psychcentral.com and write for Psychology Today as well.

What got you interested in Positive Psychology in the first place?

I went through a personal crisis and got depressed. There is nothing worse than a depressed psychologist. People would tell me what was bothering them – and I thought, Huh – you think THAT’S bad…wait until I tell you what happened to me. (I never actually said that out loud.) My best friend took me to the first International Positive Psychology Conference and I was hooked. I started doing things that made me feel better and despite all my years of training nothing seemed to be so directly helpful. That was when I decided to go to MAPP.

While googling you, I found a NYT article from 1983(!) stating you used to be a stand-up comedian. Can you tell us more about that?

Damn, I told you not to tell! 🙂 Yep, for a couple of years I was on the circuit. If you are a fan – this was back in the time of Andy Kaufman. I was mostly at the Improv in Hells Kitchen. But it was the same time I was finishing my Ph.D. I had to choose between comedy and psychology and that’s when psychodrama came along. I realized I could blend the two into a therapeutic form. Ultimately, I became a trauma expert using psychodrama to help people unlock the part of their soul that had shut down. Being able to use humor in the right amounts at the right time was part of the gift that stand-up gave me. It helps the healing when people have to touch some dark feelings.

(There is a wonderful story I will write about one day about the night Andy Kaufman told us of how “foreign man’s” “Thank you berry much.” Came about—but that’s a tale for another time.)

As stated above, among other many things, you facilitate and teach Psychodrama. What is that all about?

It is an action-oriented for of psychotherapy where we use role-playing to understand a situation, activate emotions, and correct them. In a group we will use auxiliaries to play the different roles the protagonist is talking about. If you are angry at your mother you would choose a person to play your mother and we would enact the scenes related to the issue. We use a variety of techniques to amplify and explore the emotions. We have people take on the role of someone’s feelings, their ambivalence, their compassion, or anger. It is more than simple role-playing however. The training is long (my post-doctoral training program was 13 years!) and you learn to manage dramas at an individual level, group level, and the community level. At one point I was hired by FEMA (Federal Emergency Management Agency) to use a special type of psychodrama to heal unrest in a community. It was amazing to see large groups of people respond to large-scale group dynamics with a healing result.

And how does Psychodrama tie in with Positive Psychology? Are there any parallels?

Just as psychology focused on the negative aspects and developed tools to alleviate suffering, psychodrama followed suit. Most of the training and the work was targeted at relieving pain. But the tools are so powerful that it seems the methods of psychodrama could be used to activate positive emotions in a way that strengthens and integrates.

This past summer at the IPPA conference in Montreal I was given the Avant-Garde Clinical Intervention award for the development of the Virtual Gratitude Visit (VGV). This technique builds on the original gratitude letter Marty researched. He asked students to deliver a letter of gratitude to someone they felt they needed to thank. This was one of the first pieces of research to show that the use of a positive intervention could improve well-being while stablizing depression for a period of time. In the virtual gratitude visit we use an empty chair to have the protagonist deliver a feeling of gratitude. They then reverse roles, become the person and answer, then reverse back. This is typically a very powerful and moving experience. People can do this with those that have passed on – as well as those they are no longer in touch with. Technically, with negative emotions you get a catharsis that acts like a purging. But with positive emotions you get a catharsis of integration. The expression of the positive emotions pulls together a miriad of feelings and integrates them. This creates a feeling of wholness.

I’ve developed several other experiential methods for use in exploring character strengths, forgiveness, resilience, best possible self, self compassion, etc. Each does a similar thing in using the psychodramatic methods to integrate emotions.

It seems like being a story-teller is an overarching theme in your life. Over the upcoming weeks, your memoir called American Snake Pit will be published. Here´s your space for some unbridled adulation.

I am very excited that in April George Mason’s Stillhouse press will release my memoir, “American Snake Pit: Hope Grit, and Resilience in the Wake of Willowbrook.” This will be my second memoir and it tells the story of moving a group of very challenging people into the community. It gives a voice to those who could not advocate for themselves.

My memoir is in the spirit of “One Flew Over the CooKoo’s Nest”, “Awakenings”, and “Girl Interrupted”. It challenges the perception of mental illness and is the first memoir of its kind concerning the treatment of intellectually disabled and mentally ill patients coming from the infamous Willowbrook, a hell on earth Bobby Kennedy called a “snake pit.” But it is much more than a depiction of the horrors of the institution. It is the story of patients not just surviving, but flourishing for the first time in their lives, proving the resilience and hope of the human spirit. Their story is about what happens when intentional well-being replaces indifference.

American Snake Pit is the story of the disregarded souls who ended up in my care; of the eccentric, resilient staff who helped make such a momentous success possible; and about a blind spot in American history. Because of the success and the progress made by the inmates in group homes like these, mental health became a civil right in the United States. The Civil Rights of Institutionalized Persons Act (CRIPA) of 1980, affects all Americans. It is particularly important now as the right to quality healthcare treatment, and access is so politically charged. This is the story of how it all began.

Mankind is a smart bunch. We´ve learned how to put a man on the moon, how to build skyscrapers as high as mountains, and we have access to all the knowledge in the world via small devices in our pockets made of plastic, metal, and some microchips. We can travel back and forth between the continents in a matter of hours. We´ve developed sophisticated treatments for all kinds of human ailments, helping us to become as old as some of the trees. That´s impressive and utterly admirable.

Yet, all these upsides of modern life seem to take a toll on our bodies and minds. In most Western societies, the level of obese people is growing steadily, as is the pervasiveness of psychological disorders such as depression and anxiety-related conditions. Is this the price society has to pay for the comforts of the modern life? And more importantly:

Could we reverse these effects by turning to a more “primitive” lifestyle?

Here´s the thing: I´m sure, on the whole, we´re a lot smarter than our Neanderthalian ancestors. But being smart does not automatically lead to making smarter decisions. Let´s look at their way of life for a moment. Born in 1978, I´m not a contemporary witness – yet I´m an avid reader and watch a lot of documentaries. Here´s how I imagine life must have been for them:

They lived in tribes of several larger families with close bonds between the members of their group.

They had to toil hard in order to survive, but when their work was done (having enough food to sustain the tribe), they relaxed, played, created art, and made love.

The men hunted in small groups, sometimes for several days in a row. When doing so, they walked or even ran a double-digit mileage per day.

While chasing prey, they didn’t talk much. Instead, they focused on their immediate surroundings, the animals´ smells, sounds, and their tracks.

When the hunt was successful, they returned home, shared their game with everybody, and also shared their hunting lore by the fireside.

The women also walked long distances several time per week while searching for fruits and nuts. Some of them stayed home to take care of the tribe´s offspring. When not searching for food, they created tools, pottery, and clothing.

Whenever possible, they all slept long, especially in winter. They also took several naps over the course of the day whenever the environment was save.

Now let’s take this narration and transfer into more modern terms. What we have here are people who…

spend a lot of time with their friends and the ones they love (here´s some science on the psychological upsides of bonding);

finish the equivalent of a half-marathon three or four times a week (here´s some science on the psychological upsides of intense physical exercise);

spend most of their time in natural green environments (here´s some science on the psychological upsides of biophilia)…

…and practice an intuitive form of mindfulness while doing so (here´s some science on the psychological upsides of staying in the present moment).

…yet, they are not workaholics. They know how to relax, taking lots of powernaps, and engage in recreational activities such as play and art (here´s some science on the psychological upsides of detaching from work and engaging in play or the arts).

Depression and anxiety as the body´s warning signs?

Compare this to what most Westerners are doing:

We eat too much food that we don´t have to struggle for.

We sit too much and walk too little.

We work insane hours, yet don´t sleep and play enough.

We spend too much time alone or among people we don´t really care about.

We get lost in cyberspace instead of staying with what´s at hand.

We focus too much on promoting ourselves instead of promoting the common good.

Put in simple terms, I think this is what our bodies are trying to tell us:

Hey man, you’re doing this wrong. You’re spending your time doing the wrong things, and I don’t feel safe and sound in these places you’re taking me. And where are the familiar faces that I love? But hey, I can’t explain this to you in a straight way, I don’t have words. That’s why I make you feel anxious and miserable. This is my wake-up call.

Let me close by saying that I don’t argue we should all return to an aboriginal lifestyle. I’m a city-boy all the way through. I like my work at the office, I love going out for dinner, and having a grocery store and a hospital in close proximity. But I also try to take care of myself and my body, I try to create meaning by helping people live more significant lives (e.g., via this blog…) – and ever since being married and having kids, I stay home a lot.

I guess, as ever so often, it comes down to finding the right balance.

When we think about psychological health, we typically have a kind of continuum in mind. On the one end, there are states such as satisfaction and happiness, on the other end there’s (severe) mental illness, e.g., depression and anxiety disorders. And we’re also sure all people can be located on this single dimension at any given point in time. Additionally, the absence of one state is mostly equated to the presence of the other. Accordingly, an individual is perceived as being psychological healthy when there are no signs of mental illness.

Turns out this perspective may be flawed, or rather: incomplete. Using large-scale samples, Corey Keyes is able to show that we should probably see mental health and mental illness as two interrelated, yet clearly separable dimensions. The first one is about the presence or absence of mental health, the other about the presence or absence of mental illness (please take a look at his paper Mental Illness and/or Mental Health? Investigating Axioms of the Complete State Model of Health)

When creating a matrix that is composed of these two continua, we’re able to understand psychological states on a much more nuanced level. By way of example, in his data, Keyes finds there are people who portray distinct signs of mental illness (e.g., depressive symptoms) while at the same time displaying a moderately high level of psychological health (e.g., perception of meaning in life). Conversely, there are quite a few people who are clearly neither mentally ill nor particularly healthy, a state that Keyes calls languishing. In the words of the researcher:

The current study confirms empirically that mental health and mental illness are not opposite ends of a single continuum; rather, they constitute distinct but correlated axes that suggest that mental health should be viewed as a complete state. Thus, the absence of mental illness does not equal the presence of mental health.

[…]

The diagnosis and measurement of mental health […] has provided some invaluable information. First, relatively few adults (i.e., about 2 in 10) who were free of any of the four 12-month mental disorders could be classified as flourishing or completely mentally healthy. Almost as many adults were mentally unhealthy (i.e., languishing) as were mentally healthy (i.e., flourishing), and most adults were moderately mentally healthy. Second, diagnoses less than flourishing were associated with greater levels of dysfunctions in terms of work reductions, health limitations, and psychosocial functioning. Moreover, pure languishing was as dysfunctional (sometimes more) than pure mental illness.

Especially the last sentence should give some food for thought to public health officials and corporate health executives alike. For decades, their focus has been on understanding, assessing, and mitigating mental illness. And while this certainly is an important endeavor, Keyes´ esearch clearly shows that it might be and equally pressing mission to help people find pathways from a state of low mental health (languishing) to high mental health (flourishing).

I guess that most people would be willing to agree to a statement such as: “All humans strive to be happy.” But it turns out that might be wrong.

While most people certainly try to experience happiness (in all its different facets) most of the time, there are some individuals out there that consciously and unconsciously try to avoid being happy – at least when it happens too often and/or too long. Here´s the story…

A lot of scientists in the field of psychology readily admit that their research started out as me-search – that´s investigating a topic which is highly relevant to one´s own life. Now, I´m not a scientist (by profession), but that doesn´t keep me from conducting my own (quick and dirty) research projects on the side. And more often than not, those projects certainly qualify as me-search.

General Consent

Late in 2012, I published a book here in Germany (Lizenz zur Zufriedenheit = License for Satisfaction) that is based on a coaching study I conducted in 2009/10. Back then, I tried to measure certain “meta-themes” that frequently seemed to be perceivable with my coaching clients. I created and validated a questionnaire to assess the occurrence of these themes and then correlated those numbers (among other things) with Ed Diener´s Satisfaction with Life Scale (SWLS).

There was one theme that displayed a rather strong correlation with life satisfaction (.49) and it also turned out to be the strongest predictor in a step-wise regression model. Back then, I called this factor general consent. Here are two of the items I used (roughly translated from German):

At times I believe that somehow, I am not allowed to reach my life goals.

At times I believe that somehow, I am not granted to reach my life goals.

Satisfaction with life of those people who scored high on these questions was severely diminished on average – and they also earned significantly less money. That´s why – in the end – I chose “License for Satisfaction” to be the book´s title. Some people seem to have an internal permission to reach their life goals, to be happy, and satisfied. Basically, they are free to do whatever they want. With other folks, unfortunately that´s not the case.

Introducing Self-Permission

I took up the subject once again when it was time to pick a topic for my capstone thesis (Introducing Self-Permission: Theoretical Framework and Proposed Assessment) while being enrolled in the Master of Applied Positive Psychology program at Penn. I decided to explore the idea of general consent in more detail, and to ground it in extant research. I tried to explain how it is similar and/or different from well-established psychological constructs such as self-efficacy, self-determination, optimism, self-esteem, self-acceptance, mal-adaptive schemata, and self-handicapping (among other concepts) – renaming it self-permission throughout the process. This in an overview of the nomological net I set out to explore in the paper:

To finish, I proposed a scale to measure a person´s level of self-permission – but I did not have the time to carry out an actual empirical study.* Here are a few sample items (some of them are framed in positive way, some point towards the other end of the continuum):

I do not have the permission to reach my life goals.

I have full approval to live a life full of purpose.

I am not granted to live up to my full potential.

I deserve to be everything that I can possibly be.

I do not have full endorsement to reach my life goals.

I have full consent to make the best out of my life.

Fear of Happiness

For some reason, while doing literature research back then, I did not stumble upon a very much related strand of research: In 2012, Paul Gilbert (Kingsway Hospital, Derby, UK) and colleagues published a paper where they explore a concept by the name of fear of happiness. Consistent with my own ideas, they conjecture that some individuals experience a kind of aversive conditioning with regards to positive emotional states such as contentment and happiness during childhood – where, e.g., a child is punished for being (overly) happy, or, in a milder version, where positive states are treated with indifference, e.g., because one or both parents are severely depressed (…and this is the point where research turns into me-search…).

Gilbert et al. proposed and validated a scale in order to measure fear of happiness. Here are some of their items:

Good feelings never last.

I feel I don’t deserve to be happy.

I don’t let myself get too excited about positive things or achievements.

When you are happy you can never be sure that something is not going to hit you out of the blue.

Now, here is the surprising and, to me, rather shocking news: When the researchers gave that questionnaire to a sample of about 200 people and calculated the correlation between their fear of happiness scale and an established measure of depressive symptoms, that number turned out to be .70. That´s a huge association. Here´s part of their conclusion:

[…] We were surprised by the size of the correlation at r = .70, this indicates that clinicians probably need to explore fears of happiness in detail and in terms of enhancing well-being. We should not assume that ‘challenging negative thoughts’ or increasing positive behaviours necessarily are experienced positively. […] Some depressed people really do struggle with allowing themselves to experience positive emotions in general and can have a ‘taboo on pleasure’.

I´m excited to see how, in the future, Positive Psychology might assist in helping people with this special “condition”. I sense that this will be about creating a learning process.

Learning to allow oneself to be happy, maybe even to “bear the pain” of being happy – until it hurts no more and becomes something completely normal, just the way it was meant to be.

*If you are a psychology researcher in search of an interesting research topic: I would still love to see an empirical study on self-permission come to life. In my current life as a manager, I do not have the capacity to carry out a full-blown research study – but I´d be glad to provide all of my theoretical spadework, and I could even provide funding to generate a sample via, e.g., mechanical turk. Please reach out if you´re interested…

I’m not an expert on this – but here’s my take on the issue: Our prehistoric ancestors used to walk and run a double-digit number of miles almost every day while searching and hunting for food. It’s what our bodies were made for.

Sitting around and not moving much may convey a simple message: Something’s wrong, you’re sick.

And we all know how it feels like to be sick: It’s not only on the body, typically our mood tends to deteriorate as well.

The other remedy that is available basically for free is spending time in nature. The so-called biophilia hypothesis proposes that humans (as being part of nature itself) will profit physiologically and psychologically from spending time in green spots especially parks and forests. Here’s an excerpt from an article that was recently published on Nature.com

The authors found that green spaces have a direct mental-health impact. People with better access to green space had slightly fewer depressive symptoms than those in less green areas. Independent of any potentially confounding factors, such as childhood environment and genetics, “there is something about green space itself that benefits people’s mental health.”

The causal relationship is still somewhat unclear, but my guess is that it’s the same mechanism as with phycisal exercise. Not being outside (enough) may just feel “unnatural” to our bodies, thereby signaling that something is wrong – with all the emotional consequences.

Like this:

A couple of days a go, I stumbled upon two TEDx talks by clinical neuroscientist Stephen Ilardi (University of Kansas). He shares how we can “naturally” (without taking antidepressants) fight depression. The talks are instructive and entertaining, yet pretty similar to each other – so if you´re short on time, it´s probably sufficient to watch only one of them. Here´s the summary:

We were never designed for the sedentary, indoor, sleep-deprived, socially-isolated, fast-food-laden, frenetic pace of modern life.

Accordingly, among the most potent remedies for depression are:

going outside (daylight);

moderate exercise;

eating healthy food;

getting enough sleep;

and spending time with the people you love.

And while I´m happy and impressed that these recommendations are now being backed by “hard science”, I guess we should have known all along. Here are some quotes by Greek physician and “father of Western medicine” Hippocrates (460 – 370 BC).

If you are in a bad mood go for a walk.

To do nothing is also a good remedy.

Let food be thy medicine and medicine be thy food.

What has been will be again, what has been done will be done again; there is nothing new under the sun. (Ecclesiastes 1:9)